Under the term toxic ulcers of the intestine are understood defects which develop in consequence of abnormal (toxic) products contained in the blood. Thus intestinal ulcers occur in severe forms of nephritis, especially when they are complicated with uraemic symptoms. In leukaemia and scurvy such ulcers are also met with. Intestinal ulcers arising in cases of poisoning with mercury likewise belong to this group. The ulcerative process in all these cases is best explained as due to necrosis in consequence of the altered condition of the blood.

Symptomatology

The symptoms which accompany ulcers of the intestines vary greatly. In the following we shall enumerate all the symptoms which may be met with in these conditions.

1. Diarrhoea, frequent loose movements are often present, especially if the ulcer is situated in the lower part of the large bowel. Ulcerations of the small intestines,

1 Poelchen: " Zur Aetiologie der stricturirenden Mastdarmge-schwiire." Virchow's Arch., Bd. 127. 10 caecum, and the upper end of the large bowel do not cause diarrhoea, unless there is some other complicating affection (a catarrhal condition of the bowels or an amyloid state). But even if the nicer is situated in the lower part of the colon, diarrhoea may be absent in rare instances.

2. The occurrence of blood or pus in the dejecta. Blood may be voided with the stools in consequence of a small hemorrhage of the ulcerated intestine. If there is no gastric ulcer, and other symptoms point toward intestinal ulcer, the presence of blood will help to make the diagnosis more probable. But it is by no means a positive sign, for, on the one hand, an intestinal ulcer may exist without any hemorrhages, and, on the other hand, intestinal hemorrhages may occur from other causes than ulcer. The presence of pus in the stools seems to have much greater importance. According to Nothnagel, real pus (numerous round cells) in the faeces is one of the most valuable signs of ulceration of the intestines. It is to be understood that pus may also be present in ulcerative processes accompanying neoplasms of the intestines and in abscesses which open into the intestine. The latter two conditions will have to be excluded before we can infer the existence of an intestinal ulcer from this symptom. The amount of pus in true ulcerations of the intestines is, as a rule, very small, and it is necessary to examine the dejecta quite thoroughly in order to find it While the presence of pus is so important a symptom in intestinal ulcer, its absence by no means speaks against it.

For there may be no formation of pus at the site of the ulcerative spot, or the pus may be changed to such a degree that it is no longer recognizable, especially if the ulcer is situated high up in the intestine.

3. The existence of tubercle bacilli in the dejecta is of great importance in cases in which pulmonary tuberculosis can be excluded, since they then show primary intestinal tuberculosis. The absence of the tubercle bacilli does not speak against the presence of ulcerative areas in the intestines, nor does their presence positively indicate a tuberculous affection of the intestine when pulmonary tuberculosis exists, for these microbes are then usually derived from the sputa which have been swallowed and carried down with the passages.

4. Fains. If pains exist in the abdomen in a more or less circumscribed spot for a long period of time, and if these pains are increased on pressure, they are probably due to an ulcer in the intestines. The absence of this symptom, however, speaks in no way against an ulcer, nor is its presence an absolute positive symptom for ulcer.

The general state of the system need not be disturbed, if the ulcers are only few in number and very small If their number, however, is great and their size extensive, so that a large part of the intestinal tract is involved in the ulcerative process, then nutritive disturbances will manifest themselves and marked emaciation take place.

Diagnosis

As may be seen from the description of the symptoms, the diagnosis of ulcer of the intestines is, as a rule, quite difficult. Their existence may be suspected whenever there is diarrhoea of a severe nature and more or less intense pain over a certain fixed region of the abdomen, extending over a great period of time. A positive diagnosis can be made only in the following instances:

1. If necrotic pieces of the intestinal mucosa or pus appear in the stools (in the latter instance the perforation of an abscess into the intestine has to be excluded).

2. The more or less frequent appearance of small amounts of blood quite changed in the stool, if ulcer of the stomach or vicarious bleeding can be excluded.

3. Diarrhoea and the constant appearance of tubercle bacilli in the stools, when pulmonary tuberculosis can be excluded. This points to the presence of tuberculous processes (ulcers) in the intestine.

4. If the ulcers are situated in the lower part of the colon or rectum and are accessible to a direct visual examination.

The nature of the ulcers (whether catarrhal, tuberculous, syphilitic, or toxic) must be elucidated by a thorough knowledge of the history of the case and the results of an accurate examination of the patient.

Prognosis

The prognosis of intestinal ulcers will depend largely upon their number, size, and nature. A few small catarrhal ulcers will heal quickly without any further trouble. Amyloid ulcers hardly ever show a tendency to heal. Tuberculous ulcerations occasionally are amenable to treatment, still more so are the syphilitic ulcers. Very extensive ulcerations, no matter of what nature, are very dangerous to life.

Treatment

In the treatment of intestinal ulcers the etiological factors play the greatest part. Thus, in tuberculous ulcers general hygienic rules will have to be observed. An out-of-door mode of living, and, if possible, in the mountains, should be recommended. Guai-acol carbonate, creosote, ichthalbin are of value. In syphilitic ulcers general anti-syphilitic treatment should be instituted: inunctions with mercury, or injections of sublimate or calomel, or the administration of large doses of potassium iodide. In toxic ulcers (as those due to uraemia and mercurial poisoning) the treatment must be directed against the primary trouble. Besides the etiological therapy, intestinal ulcers require specific and symptomatic treatment. The treatment directed to the healing of the ulcers is very successful if the latter are situated in the rectum or in the lower part of the colon, while this object can hardly be attained if they exist high up in the colon or in the small intestine. In the former instance the ulcers, if accessible to view, may be directly treated by the application of a strong solution of nitrate of silver or pro-targol. If not visible but situated in the colon, injections of a 0.2 to 1 per cent. solution of nitrate of silver or of tannic acid of the same strength into the bowels are of value.

If the ulcers are situated in the small intestine, large doses of subnitrateof bismuth (1 to 2 gm. [gr. xv. to xxx.] three times a day) may be tried. The symptoms which accompany the ulcer and vary from time to time will have to be treated as such. Diarrhoea, hemorrhage, and pain must be combated with the customary remedies.

Most patients should be kept abed for some time. The application of a hot-water bag or a wet pack over the abdomen is very beneficial.

The diet should contain nourishing but easily digestible and non-irritating food. Thus, milk, kumyss, matzoon, eggs beaten up in milk, soft-boiled eggs, farina, oat meal cooked in milk, mutton broth, chicken soup, scraped beef, calf's brain, sweetbreads, cacao, tea, and toast may be given.